chapter 62 care of patients with problems of the biliary system and pancreas mrs. kreisel msn, rn...
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Chapter 62
Care of Patients with Problems of the Biliary System and Pancreas
Mrs. Kreisel MSN, RNNU130 Adult HealthSummer 2011
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Hepatobiliary Anatomy
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Acute Cholecystitis
• Acute cholecystitis is the inflammation of the gallbladder.
• Calculous cholecystitis.• Cholelithiasis (gallstones) usually accompanies
cholecystitis.• Acalculous cholecystitis inflammation can occur
in the absence of gallstones.
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Gallstones
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Chronic Cholecystitis
• Repeated episodes of cystic duct obstruction result in chronic inflammation
• Pancreatitis, cholangitis• Jaundice• Icterus• Obstructive jaundice• Pruritus
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Clinical Manifestations
• Flatulence, dyspepsia, eructation, anorexia, nausea and vomiting, abdominal pain
• Biliary colic• Murphy’s sign• Blumberg’s sign• Rebound tenderness• Steatorrhea
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Nonsurgical Management
• Nutrition therapy—low-fat diet, fat-soluble vitamins, bile salts
• Drug therapy—opioid analgesic such as morphine or hydromorphone, anticholinergic drugs, antiemetic
• Extracorporeal shock wave lithotripsy • Percutaneous transhepatic biliary catheter
insertion
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Surgical Management
• Laparoscopic cholecystectomy• Standard preoperative care• Operative procedure• Postoperative care:
• Free air pain result of carbon dioxide retention in the abdomen
• Ambulation• Return to activities in 1 to 3 weeks
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Traditional Cholecystectomy
• Standard preoperative care• Operative procedure• Postoperative care:
• Opioids via patient-controlled analgesia pump• T-tube• Antiemetics• Wound care
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Traditional Cholecystectomy (Cont’d)
• Care of the T-tube• NPO• Nutrition therapy
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Cancer of the Gallbladder
• Anorexia, weight loss, nausea, vomiting, general malaise, jaundice, hepatosplenomegaly; chronic, progressively severe epigastric or right upper quadrant pain
• Poor prognosis• Surgery, radiation, chemotherapy
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Acute Pancreatitis
• Serious and possibly life-threatening inflammatory process of the pancreas
• Necrotizing hemorrhagic pancreatitis• Lipolysis• Proteolysis• Necrosis of blood vessels• Inflammation• Theories of enzyme activation
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Autodigestion
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Complications of Acute Pancreatitis
• Hypovolemia• Hemorrhage• Acute renal failure• Paralytic ileus• Hypovolemic or septic shock• Pleural effusion, respiratory distress syndrome,
pneumonia• Multisystem organ failure• Disseminated intravascular coagulation• Diabetes mellitus
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Clinical Manifestations
• Generalized jaundice• Cullen’s sign• Turner’s sign• Bowel sounds• Abdominal tenderness, rigidity, guarding• Pancreatic ascites• Significant changes in vital signs
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Laboratory Assessment
• Lipase• Trypsin• Alkaline phosphatase• Alanine aminotransferase• WBC• Glucose• Calcium
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Acute Pain
• Interventions include:• The priority for patient care to provide
supportive care by relieving symptoms, decrease inflammation, and anticipate and treat complications
• Comfort measures to reduce pain including fasting and drug therapy
• Endoscopic retrograde cholangiopancreatography
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Nonsurgical Management
• Fasting and rest• Drug therapy• Comfort measures• Endoscopic retrograde
cholangiopancreatography (ERCP)
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Surgical Management
• Preoperative care—NG tube may be inserted• Operative procedures• Postoperative care:
• Monitor drainage tubes and record output from drain.
• Provide meticulous skin care and dressing changes.
• Maintain skin integrity.
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Imbalanced Nutrition: Less Than Body Requirements
• Interventions include:• NPO in early stages• Antiemetics for nausea and vomiting• Total parenteral nutrition• Small, frequent, moderate- to high-
carbohydrate, high-protein, low-fat meals• Avoidance of foods that cause GI stimulation
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Chronic Pancreatitis
• Progressive destructive disease of the pancreas, characterized by remissions and exacerbations
• Nonsurgical management includes:• Drug therapy• Analgesic administration• Enzyme replacement• Insulin therapy• Nutrition therapy
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Pancreatic Abscess
• Most serious complication of pancreatitis; always fatal if untreated
• High fever• Blood cultures• Drainage via the percutaneous method or
laparoscopy• Antibiotic treatment alone does not resolve
abscess
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Pancreatic Pseudocyst
• Complications: hemorrhage, infection, bowel obstruction, abscess, fistula formation, pancreatic ascites
• May spontaneously resolve• Surgical intervention after 6 weeks
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Insulinoma
• Most common type of neuroendocrine pancreatic tumor
• Benign tumors of the islets of Langerhans that cause excessive insulin secretion and subsequent hypoglycemia
• Management—removal of tumor
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Pancreatic Carcinoma
• Nonsurgical management:• Drug therapy• Radiation therapy• Biliary stent insertion
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Surgical Management
• Preoperative care:• NG tube may be inserted• TPN typically begun
• Operative procedure may include Whipple procedure
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Surgical Management (Cont’d)
• Postoperative care:• Observe for complications• GI drainage monitoring• Positioning• Fluid and electrolyte assessment• Glucose monitoring
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Whipple ProcedureThree anastomoses that constitute the Whipple procedure: Choledochojejunostomy, pancreaticojejunostomy,
& gastrojejunostomy
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•NCLEX TIME
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Question 1
A patient with chronic cholecystitis is complaining of
pruritus, clay-colored stools, and voiding dark, frothy
urine. Which laboratory analysis is a priority in the
nurse’s assessment of this patient?
A. Liver function tests B. Total bilirubinC. Lipase level D. White blood cell count
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Question 2
Which patient is more likely to develop gallstones?
A. 55-year-old African-American male with a history of diabetes mellitus
B. 62-year-old American-Indian femaleC. 45-year-old Caucasian female with a
family history of gallstonesD. 60-year-old obese, Mexican-American
female with a history of diabetes mellitus
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Question 3
The nurse notes jaundice and bluish discoloration of the
abdomen and flank in the patient complaining of
abdominal pain of sudden onset that radiates to the left
shoulder. Based on these symptoms, what intervention
should be the priority for this patient?
A. Passage of a nasogastric tube B. Observation for delirium tremens C. Pain reliefD. Relief from vomiting
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Question 4
About how any Americans are affected by acute
pancreatitis?
A. 10,000 B. 30,000 C. 50,000 D. 80,000
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Question 5
In the care of a patient with acute pancreatitis, which
assessment parameter requires immediate nursing
intervention?
A. Heart rate 105 beats/min B. Blood pressure 110/82 mm HgC. Respiratory rate 28 breaths/minD. Serum glucose 136 mg/dL